Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you prefer assessing cystatin C or creatinine when monitoring a patient’s eGFR who is receiving chemotherapy for malignancy?
If the patient is on a drug known to interfere with creatinine handling in the renal tubules (e.g. abemaciclib), then I will intermittently check the cystatin C to differentiate true AKI from pseudo-hypercreatinemia since these drugs can also cause true AKI.
What is your approach to lab and imaging monitoring in a patient with an elevated creatinine following a unilateral nephrectomy?
One should expect some elevation in serum creatinine after unilateral nephrectomy in the majority of patients. Hyperfiltration seems to be universal but is often not complete. Over time, the serum creatinine stabilizes and often improves some but likely not to baseline. I would repeat serum creatini...
How do you manage patients on biologics peri-operatively?
There was an article in the NEJM Journal Watch in regards to stopping biologics (DMARDs and TNFs) for rheum disease before surgery, and there was no statistically significant benefit in regards to surgical recovery but, as expected, flares of the Rheum disease. In regards to the newer targeted injec...
What is the antifungal prophylaxis regimen that you use in patients on peritoneal dialysis who are receiving antibiotics?
Data indicates that either nystatin (500,000 U qid) or fluconazole (200 mg q48 hours) is effective in minimizing the risk of fungal peritonitis in PD patients being treated with antibiotics. See the most recent ISPD guidelines (Kam-Tao Li et al., PMID 35264029) for details. As there is less risk of ...
Would you consider PTH-analog therapy in a woman with osteoporotic vertebral fractures who has asymptomatic non-obstructive renal stones and normal 24-hour urine calcium level?
With the limited information posted, my answer would be yes. I would likely choose abaloparatide as it seems to have less of an issue with hypercalciuria than teriparatide. Another option for an “anabolic" drug would be Romosozumab which would not be a drug about which hypercalciuria is a concern.
When would you consider neuro-stimulants in post-stroke patients?
To my knowledge, there are no large, randomized trials supporting the use of neurostimulants in stroke rehabilitation. When patients are too sleepy to participate in therapy, I have been known to use very low-dose methylphenidate or modafinil. Levodopa has also been tried with mixed results.
Do you recommend the HPV vaccine for patients with recalcitrant verruca vulgaris?
Yes, I recommend the HPV vaccine for children and adolescents of eligible age. I have seen warts resolve after vaccine administration. There are reports of dramatic resolution after vaccination. A cross-protective mechanism of action is suggested. Literature suggests there may be an age-dependent re...
Do you recommend initiating a potassium sparing diuretic in patients with recurrent nephrolithiasis who have hypercalciuria but do not tolerate thiazide diuretics?
No. The idea of using a thiazide diuretic as a preventive treatment for calcium-containing stones is its hypocalciuric effect. Potassium-sparing diuretics do not have this ability. Loop diuretics worsen hypercalciuria and, in general, are inappropriate for use in calcium stone formers. One could con...
Would you consider GLP1 R agonist therapy in a patient with a history of severe gallstone pancreatitis that is now post cholecystectomy?
In the context of shared decision-making, I would consider prescribing an GLP-1RA on someone with a history of severe gallstone pancreatitis post cholecystectomy. The critical issue is for the patient to understand the uncertainty about the safety of the approach and be willing to take on that risk....
What is your approach to ongoing assessment and medication tapering in well controlled discoid lupus without systemic features?
As with many systemic lupus (SLE) complications, the patient with discoid lupus (DLE) is often best managed by a rheumatologist in tandem with a specialist of that complication, in this case, a good medical dermatologist experienced with cutaneous lupus. Although I think I am good at telling most ac...